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Carpal Tunnel Syndrome

Carpal tunnel syndrome is the most common thing that we see. The symptoms are pain and burning in the wrist and hands. Often it is not that well localized. Often they complain that the entire hand is numb. The pain may radiate up to the arm, even up into the neck if it is very severe and very acute. Paresthesia and numbness are common.

Symptoms are very prominent at night, especially if the patients just happen to fold their wrists in a certain position. They may actually wake up with their hand asleep and have to shake it out in order to get the feeling back into it. Also, clumsiness. They don’t have - even if they have normal sensation on exam - they don’t feel the dexterity is there in their hand. Physical findings; the Tinel’s sign. I find that that’s by far and away the best. You can do this with your finger, just like when you percuss or even with a reflex hammer over the carpal tunnel, which the best spot is over the area between the thenar eminence.

The hypothenar evidence marks the location of the carpal tunnel. If you tap there and the patient has pain, either radiating into their hands somewhere, their thenar evidence or their fingers, or up into their forearm, I consider that a positive sign. The Thalence is not quite as good. That’s where you bend the wrist, either flex it or extend it for the reverse Thalence and then let it sit there for awhile. I don’t find that is quite as useful. I don’t feel like wasting a minute, having them sit there if the Tinel’s sign is positive, that’s good enough for me. You may have abnormal sensory findings, occasionally weakness or even atrophy which is, in my experience, very unusual. Probably a hand surgeon or orthopedist see this a lot more. This just shows you the difference in nerve distribution, the median nerve is generally the first three-and-a-half fingers. Although it is very rare, I have had some patients say, "Why does the middle part of my finger feel strange and the outside of my finger feel normal?" I’ve had maybe twice that that’s happened, so most of the time they don’t differentiate it quite that precisely. You can see the ulnar nerve is the other part of the hands and also extends on to the dorsum, which the medial nerve does not affect the dorsum. That’s the radial nerve. This is one of the maybe two patients I’ve seen who had thenar atrophy carpal tunnel syndrome, carpel tunnel syndrome, carpal tunel syndrome. He had carpal tunnel syndrome for a long time and I just sent him right to the hand surgeon because that’s pretty serious when you get motor involvement.

The other thing to remember is that carpal tunnel syndrome, like ulnar entrapment or tarsal tunnel syndrome, can be associated with certain underlying medical conditions. Diabetes is a big one. Hypothyroidism. I have picked up a few patients with hypothyroidism that were before undiagnosed. Occasionally gout, acromegaly because of changes at the specific sites, the wrist joint, pregnancy - obviously, that will resolve - synovitis at the wrist, particularly in RA, systemic sclerosis or

The treatment includes, if they have an underlying condition like thyroid disease or diabetes, treat the hypothyroidism, that will often help. Rheumatoid arthritis, treating the synovitis with an injection in the wrist or maybe systemic treatment. That may help. Antiinflammatory drugs may help. Wrist splinting will help, particularly at nighttime. Keep the wrists in good position so the patients at least won’t wake up with the feeling that their hand is

Corticosteroid injection into the carpal tunnel is very useful. If a patient does not respond to these things or they have significant motor involvement - really any motor involvement - I just refer them for surgical release. If I think a patient needs surgery, that’s the instance where I will get an EMG with nerve conduction study. Otherwise if I have a clinical diagnosis and I am just doing these rather simple treatments, I don’t even bother with the study. My personal thing, it’s just a waste of time and money. Very few patients enjoy having these studies done. If any of you have ever had it done - and I have as part of an experiment - it’s annoying at the least. It is uncomfortable. But before I refer a patient to a surgeon I want to document what’s going on and see how

This is the standard, this is a 3M splint, very similar to the Futura. It has a metal stay in the bottom of the wrist and you can take it out and wash the splint. It’s pretty hardy. The only problem is that you can’t switch it from left to right. It’s really for one hand only.

Repetitive strain injury. I’m sure you’ve had patients coming in complaining of this. It’s more of a legal problem. You know, doctors get involved in this because of the legal implications. Patients who work in the office, particularly women who work in an office setting, using computers a lot, doing a lit of filing, using their hands, they get this repetitive strain injury which can include sort of non-specific wrist tendonitis, sometimes carpal tunnel. The reason it becomes a problem is because patients are looking for disability. I don’t want to say that they are really looking for it, but they don’t feel that they can function anymore and that that’s their livelihood and it was related to work. There has been no definite cause and effect relationship, although in some patients that I’ve seen - particularly young women with very thin wrists, thin fingers - their tendons are going to be thinner. They probably just can’t withstand the amount of stress that’s put on them. Just like a pitcher who is more muscular is going to have less shoulder problems than a pitcher who is relatively thin. I think in some instances - It’s my feeling- that it is a true cause and effect relationship but it has not been proven scientifically. It’s just something to be aware of. Sometimes you